Caregiver Application
Total Page：16
File Type：pdf, Size：1020Kb
CAREGIVER APPLICATION
Visiting Angels is an equal opportunity employer, dedicated to a policy of non-discrimination on any basis including race, color, age, sex, religion, disability, national origin or marital status. All information on this application is confidential.
General Contact Info Last Name: First Name: Middle Int. Address Apt #: City: State: Zip: Home Phone: Cell Phone: E-Mail: Date:
Position & Availability I’m applying for a position as: Hours you are Schedule Desired: Times Not Available: Are you available for available: emergencies?
Are you available for 24hr live-in position? Yes No 3 Days 4 Days 5 Days
Hourly Wage Required: Are you a legal US citizen Yes No
Are you eligible to work in the US? Yes No
Comments:
Transportation Some caregiving positions require a valid driver’s license or a car, including valid insurance coverage Do you have a valid license? Yes No State:
Do you have a car? Yes No Make & Model:
If yes, do you have valid insurance? Yes No
Proof of Insurance (see attached photocopy)
Page 1 of 4 01/01/2014 Education High school: City/State: Dates: College: City/State: Dates: Other: City/State Dates: Degree/certification:
Special skills or training
Experience Discuss any training or experience you’ve had with the elderly:
What do you enjoy most about working with the elderly?
What do you like the least about working with the elderly?
Criminal History Have you ever been convicted of a felony or misdemeanor? Yes No
If yes, please explain
Emergency Contact Information Name Relationship Phone (cell) Phone (home)
Page 2 of 4 01/01/2014 Employment History Current Employer May we contact your current employer? Yes No Company From: To: Job Title: Reason for leaving? Duties:
Supervisor: Phone number:
Company: From: To: Job Title: Reason for leaving? Duties:
Supervisor: Phone number:
Company: From: To: Job Title: Reason for leaving? Duties:
Supervisor: Phone number:
Company: From: To: Job Title: Reason for leaving? Duties:
Supervisor: Phone number:
Company: From: To: Job Title: Reason for leaving? Duties:
Supervisor: Phone number:
Page 3 of 4 01/01/2014 Certification and Release: I certify the above stated and indicated are true in fact and no misrepresentation of myself has been made. I understand that any false information, omissions or misrepresentation of facts will result in rejection of this application and/or discharge at any time during employment. I authorize Visiting Angels to verify any and all information contained within this application, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies & law enforcement authorities to release any information concerning my background & hereby release any said persons, schools, companies & law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment and that I am willing to submit to drug testing at any time to detect the use of illegal drugs prior to or during employment.
Restrictive Covenant: I agree not to do business directly with any individual or business entity that Visiting Angels has introduced to me or by entering into employment with such individuals or businesses.
Applicant’s Signature: ______Date:______
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For Office Use Only
Application Reviewed By: ______Date: ______
CG Interviewed By: ______Date: ______
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